Table 3.
Final framework for the essential data element in differential diagnosis of oral medicine
| Data sections | Data elements | Variables |
|---|---|---|
| Administrative data | ||
| Demographic | Identification number | |
| Gender | Male/female | |
| Age group | ||
| Race | ||
| Marital status | Single/married | |
| Education | ||
| Employment | ||
| Address | ||
| Mobile | ||
| Provider ID | Specialties | |
| Date of acceptance | ||
| Record number | ||
| Diagnostic | Chief complaint | |
| Primary diagnosis | ||
| Differential diagnosis | ||
| Final diagnosis | ||
| Historical data | ||
| Social history | Number of caffeinated beverages you drink in a day | |
| Number of alcoholic beverages you drink in a week | ||
| Number of carbonated beverages a day | ||
| Have you ever used tobacco? | Yes/no | |
| If yes, what type | Cigarette, pipe/cigar, smokeless | |
| Do you currently use tobacco? | Yes/no | |
| If yes, average number of uses per day | ||
| For how many years? | ||
| Exposure to sunlight? | Yes/no | |
| Oral hygiene history | How often do you brush? | 1/1>/1< |
| How often do you floss? | Once per night, once per week, i do not use | |
| Do you take fluoride supplements? | Yes/no | |
| Family history | Genetic Diseases | Yes/no |
| Involvement of family members in infectious diseases | Yes/no | |
| Food allergy | Yes/no | |
| Drug allergy | Yes/no | |
| Past disease history | Past previous malignancies | Yes/no |
| History of thyroid disorders | Yes/no | |
| History of radiotherapy | Yes/no | |
| History of liver disease | Yes/no | |
| Endocrine disorders such as diabetes | Yes/no | |
| Immune system diseases such as HIV | Yes/no | |
| Infection with human papilloma virus, HPV 16,18 | Yes/no | |
| Para clinical indicator | ||
| Radiography | Extraoral radiographs | OPG/DPT, lateral Ceph, PA view, waters |
| Intraoral radiographs | Bitewing radiographs, occlusal radiographs, periapical radiographs, full mouth series | |
| CT or CAT scan | ||
| Radiography result | ||
| Laboratory | Main group of test | Cytology, biochemistry, hormone tests, microbiology, pathology |
| Tests results | ||
| Biopsy | ||
| Aspiration | ||
| Diascopy | ||
| Clinical indicator | ||
| Ulcerative, vesicular, and bullous lesions | Features | Isolated lesion, multiple lesions, persistent lesion, recurrent lesion |
| Site | ||
| Size | ||
| Duration | ||
| Tendency/pain | Yes/no | |
| Predisposing factors | ||
| Associations/relieving factors | ||
| Previous treatment | ||
| Hemorrhage | Yes/no | |
| Description of margins | Regular, irregular, rolled | |
| Lymphadenopathy | Yes/no | |
| Depth | Superficial, deep | |
| Other features | Vesicle, bulla, plaque, papule, nodule, tumor solid | |
| Altered sensation | Yes/no | |
| If yes, please describe the nature and distribution | ||
| Red and white lesions of the oral mucosa | Features | Isolated lesion, multiple lesions, persistent lesion, recurrent lesion |
| Color | Red lesions, white lesions, pigmented lesions | |
| Site | ||
| Size | ||
| Duration | ||
| Tendency/pain | Yes/no | |
| Predisposing factors | ||
| Associations/relieving Factors | ||
| Previous treatment | ||
| Hemorrhage | Yes/no | |
| Recent increase in size | Yes/no | |
| Description of margins | Regular, irregular, rolled | |
| Color nature | Homogeneous, heterogeneous | |
| Depth | Superficial, deep | |
| Other features | Vesicle, bulla, plaque, papule, nodule, tumor solid | |
| Ulceration | Yes/no | |
| If yes, describe appearance | ||
| Lymphadenopathy | Yes/no | |
| Discharge | Yes/no | |
| If yes, please describe the nature of discharge | ||
| Altered Sensation | Yes/no | |
| If yes, please describe the nature and distribution | ||
| Pigmented lesions of the oral mucosa | Features | Isolated lesion, multiple lesions, persistent lesion, recurrent lesion |
| Color | Red lesions, blue lesions, brown lesions, black lesions, pigmented lesions | |
| Color nature | Homogeneous, heterogeneous | |
| Site | ||
| Size | ||
| Duration | ||
| Tendency/pain | Yes/no | |
| Predisposing factors | ||
| Associations/relieving factors | ||
| Previous treatment | ||
| Hemorrhage | Yes/no | |
| Description of margins | Regular, irregular, rolled | |
| Depth | Superficial, deep | |
| Other features | Vesicle, bulla, plaque, papule, nodule, tumor solid | |
| Altered sensation | Yes/no | |
| If yes, please describe the nature and distribution | ||
| Benign lesions of the oral cavity and the jaws | Features | Isolated lesion, multiple lesions, persistent lesion, recurrent lesion |
| Color | Red lesions, colored tissue, white lesions, blue lesions, yellow lesions | |
| Site | ||
| Size | ||
| Duration | ||
| Tendency/pain | Yes/no | |
| Predisposing factors | ||
| Associations/relieving factors | ||
| Previous treatment | ||
| Hemorrhage | Yes/no | |
| Lesion process | Fast, slow | |
| History or evidence of infective etiology | Yes/no | |
| Shape features | Polypoid, sessile, Peduncalate, nodular, domed | |
| Surface | Smooth, papillary, verrucous, granulomatous | |
| Consistency | Soft, firm, hard, rubbery, cheesy | |
| Lymphadenopathy | Yes/no | |
| Ulceration of Surface | Yes/no | |
| If yes, describe appearance | ||
| Altered sensation | Yes/no | |
| If yes, please describe the nature and distribution | ||
| Oral and oropharyngeal cancer | Site | Localized, generalized |
| Number | Single, multiple lesion | |
| Margins | Coalescing, well defined | |
| Duration | ||
| Tendency/pain | Yes/no | |
| Predisposing factors | ||
| Associations/relieving factors | ||
| Previous treatment | ||
| Lymphadenopathy | Yes/no | |
| Lesion process | Fast, slow | |
| History or evidence of infective etiology | Yes/no | |
| New primary cancer or recurrence | New primary, primary – secondary, recurrence, metastasis, not stated | |
| Histological grade | Grade 1: Well differentiated, Grade 2: Moderately differentiated, Grade 3: Poorly differentiated | |
| Depth of invasion | ||
| Perineural invasion | Yes/no | |
| Involved or close margins with measurements | Length×width×thickness in mm | |
| Tumor stage | Stage 0, Stage I, Stage II, Stage III, Stage IVA, Stage IVB, Stage IVC | |
| Shape features | Polypoid, sessile, Peduncalate, nodular, domed | |
| Surface | Smooth, papillary, verrucous, granulomatous | |
| Consistency | Soft, firm, hard, rubbery, cheesy | |
| Lymphadenopathy | Yes/no | |
| Ulceration of Surface | Yes/no | |
| If yes, describe appearance | ||
| Altered sensation | Yes/no | |
| If yes, please describe the nature and distribution | ||
| Salivary gland diseases | Features | Isolated Lesion, Multiple Lesions, Persistent Lesion, Recurrent Lesion |
| Color | Red lesions, colored tissue, white lesions, blue lesions, yellow lesions | |
| Site | ||
| Size | ||
| Duration | ||
| Tendency/pain | Yes/no | |
| Predisposing factors | ||
| Associations/relieving factors | ||
| Previous treatment | ||
| Hemorrhage | Yes/no | |
| Milking | Normal, parotid, submandibular, sublingual | |
| Pooling | Yes/no | |
| Salvia nature | Clear, turbid | |
| Dry mouth | Yes/no | |
| Period | Night, day, both | |
| Dry other parts of the body (eyes, skin, throat, vagina, etc.) | Yes/No | |
| Swallowing difficulties | Yes/no | |
| Opening mouth difficulties | Yes/no | |
| Speaking difficulties | Yes/no | |
| The amount of salivation | Little, a lot, normal | |
| Skull – pink disorders | Yes/no | |
| Intraoral symptoms | Severe decay, severe abrasion, candidiasis, enamel hyperplasia, atrophy of the oral mucosa | |
| History of fill and empty | Yes/no |
CAT=Computed axial tomography, CT=Computed tomography, OPG/DPT=Orthopantomogram/Dental Panoramic Tomogram, PA=It’s not acronym